Bariatric Times

SEP 2017

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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20 Case Series Bariatric Times • September 2017 gastro-jejuno anastomosis was manually created with 00 absorbable suture. With this, pressure to the fistula was released and closure was achieved with the help of the serosal patch of the Roux limb. The patient had a good evolution, tolerating oral feeding with no evidence of the fistula using contrast media in the postoperative period. DISCUSSION One critical step in performing the RYGB is the creation of the gastric pouch along with the gastro- jejuno anastomosis. Complications of the gastric pouch, such as leaks, stenosis of the anastomosis, and marginal ulcers with bleeding, seem to be related to staple line disruption and the formation of fistulas between the gastric pouch and the excluded stomach. 8 Capella et al and Fobi et al 9 –11 have recommended gastric bypass techniques that interpose a segment of jejunum between the gastric reservoir and the excluded stomach. This works as a patch and prevents fistulas occurring between these two structures. It is important to note that the jejunal interposition is a safeguard that minimizes the recurrence of leak, but is not the reason for the healing of the fistula; placement of the stitches to close the fistula and converting to a gastric bypass reduced the pressure in the pouch that resulted in the healing. Capella et al 10 reported good results with interposition among 652 consecutive patients (average BMI 50kg/m 2 [range: 38–86kg/m 2 ] with no previous bariatric surgical history who underwent RYGB using this technique. In this retrospective analysis, they found, at five years postoperative, no incidences of fistula. Early reoperation rate was 0.5 percent and the incidence of late complications that required reoperation was 0.5 percent. At five years, the patients average BMI was reduced to 29kg/m 2 [range: 20– 43kg/m2], and 93 percent of patients lost more than 50 percent excess weight. The authors have reported their experience with this technique, demonstrating a reduction in postoperative complications. 1 2 Although the available literature describes treatment of gastric fistula post-LSG, no one approach has been proved to be superior. In the cases presented herein, the authors applied the same methods described by Capella et al and Fobi and Lee, and obtained successful results. Although the authors believe that the best way to treat a complication is with a good surgical technique to avoid its appearance, they acknowledge the importance and need of prospective studies that demonstrate the effectiveness of treatments, such as jejunal interposition, when complications occur. CONCLUSION Given the rise in popularity of the LSG procedure worldwide, surgical teams must prepare for possible complications in the postoperative period. Gastric fistula, though not the most common complication of LSG, has many treatments described in the literature, from conservative to more aggressive. The authors still believe that the treatment for a gastric fistula should start with the less aggressive option and give the patient the opportunity to heal without re-intervention. In cases where this approach fails, conversion to RYGB with an interposed jejunal loop, may be considered. REFERENCES 1. Angrisani L, Santonicola A, Iovino P, et al. Erratum to: Bariatric surgery and endoluminal procedures: IFSO Worldwide Survey 2014. Obes Surg. 2017;27(9):2290–2292. 2. American Society for Metabolic and Bariatric Surgery. Estimate of Bariatric Surgery Numbers, 2011- 2015. https://asmbs.org/resources/estima te-of-bariatric-surgery-numbers. Accessed June 8, 2017. 3. Abraham A, Ikramuddin S, Jahansouz C, et al. Trends in bariatric surgery: procedure selection, revisional surgeries, and readmissions. Obes Surg. 2016;26(7):1371–1377. 4. Abou Rached A, Basile M, El Masri H. Gastric leaks post sleeve gastrectomy: Review of its prevention and management. World J Gastroenterol. 2014;20(38):13904–13910. 5. Rosenthal RJ. International Sleeve gastrectomy expert panel consensus statement: best practice guidelines based on experience of more than 12,000 cases. Surg Obes Relat Dis. 2012;8(1):8–19 6. El Mourad H, Himpens J, Verhufstadt J. Stent treatment for fistula after obesity surgery: results in 47 consecutive patients. Surg Endosc. 2013;27:808–816 7. van de Vrande S, Himpens J, El Mourad H, Debaerdemaeker R, Leman G. Management of chronic proximal fistulas after sleeve gastrectomy by laparoscopic Roux- limb placement. Surg Obes Relat Dis. 2013;9(6):856–861. 8. Byrne TK. Complications of surgery for obesity. Surg Clin North Am. 2001;81:1181e93. 9. Capella JF, Capella RF. Gastro- gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction. Obes Surg. 1999;9:22–27 10. Capella JF, Capella RF. An assessment of vertical banded gastroplasty-Roux- en-Y gastric bypass for the treatment of morbid obesity. Am J Surg. 2002;183(2):117–123. 11. Fobi MAL, Lee H. The surgical technique of the Fobi-Pouch operation for obesity (the transected silastic vertical gastric bypass). Obes Surg. 1998;8(3):283–288. 12. Zorrilla PG, Salinas RJ, Salinas- Martinez AM. Vertical banded gastroplasty-gastric bypass with and without the interposition of jejunum: preliminary report. Obes Surg. 1999;9(1):29–32. FUNDING: No funding was provided. DISCLOSURES: The authors report no conflicts of interest relevant to the content of this manuscript. AUTHOR AFFILIATION: Luis Fernando Zorrilla Núñez, MD; Pablo Gerardo Zorrilla Blanco, MD; Noé Núñez Jasso, MD; and Álvaro Tristán Peralta, MD, are from University Hospital, Autonomous University of Nuevo Leon, Mexico. ADDRESS FOR CORRESPONDENCE: Luis Fernando Zorrilla Núñez, MD, Belisario Domínguez 2549, Col Obispado Monterrey Nuevo Leon, Mexico; E-mail: drluiszorrilla@gmail.com FIGURE 9. Preoperative swallow barium study demonstrating a gastric leak FIGURE 10. Postoperative swallow barium study without evidence of leak or obstruction

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